=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356682728
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR STEPHEN C HOLMES, DDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2013
-----------------------------------------------------
Last Update Date | 03/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 189 GREENBRIAR BLVD SUITE A
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70433-7234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-400-4539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 189 GREENBRIAR BLVD SUITE A
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70433-7234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-400-4539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHEN COLE HOLMES
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 504-400-4539
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 5923
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------